Rowan being a very cooperative 2 year old, just a few weeks before he was killed

Special Needs Discrimination in Healthcare. It’s real, just like it is real throughout our society.

I was naive. I had seen it in my everyday life with Rowan.. in the occasional act of unnecessary compassion from a friend, in a therapist who thought his diagnosis defined his capabilities, in the surprised look of an acquaintance when we said that he would be attending her child’s preschool, in the occasional look of pity from a stranger. But I never expected to see it from a doctor. Rowan hadn’t ever been sick, so I didn’t have the chance to learn what other parents already knew, and I was blindsided.

We believe that special needs discrimination is the ultimate reason why our son was killed.

After learning of the CDPH report, we believe that Rowan was discriminated against because of his diagnosis, and therefore killed.

We believe this because:
1. Based on Rowan’s special needs diagnosis (not on Rowan as a person), Dr. Raymond Fripp labeled Rowan as “uncooperative”
2. Because of this label, Dr. Raymond Fripp ordered the use of general anesthesia (which was dangerous for Rowan) for a diagnostic procedure
3. Because of Dr. Raymond Fripp’s label, Dr. Kathleen Kaya was not required to, and did not, provide precautions typical in all general anesthetic procedures
4. Because of #2 and #3, Rowan was killed
5. And finally, because Rowan had a special needs diagnosis, the hospital was able to justify his abysmal care. Because Rowan had special needs, the California Department of Health was able to support the hospital’s justification, and the Medical Board of California was able to ignore it.

And we ask, why aren’t we talking about it?

If I am truthful with myself, I realize that I have even been guilty of special needs profiling at some level. Have you? I was lucky enough to have Rowan, who gave me the opportunity to see the world from a different and much better perspective. I hope that you have taken the opportunity to see the world from his perspective, too.

“You do not have the right to say to a person: I don’t see you the way you are, I want to see you as I would be more comfortable seeing you.” Jane Elliot
I saw Jon Stewart’s piece about Eric Gardner, and I cried. I cried for Eric and his family, but I also cried because Eric’s story felt like another sucker-punch to my stomach.

I don’t think many people realize how connected we feel to these types of stories. Change the police to doctors; change racial discrimination to special needs discrimination, and you have us. Some may think that is too extreme a view, so it is a view that we don’t share with others often. But it is how we feel every day.

I don’t say this to discount racial discrimination or Eric’s personal story, but to point out that discrimination and unfairness in our society and justice system is present at many levels.

After learning of the CDPH report, we are worried that Rowan was discriminated against because of his diagnosis, and therefore killed.

We feel this way because:
1. Based on Rowan’s special needs diagnosis (not on Rowan as a person), Dr. Raymond Fripp labeled Rowan as “uncooperative”
2. Because of this label, Dr. Raymond Fripp ordered the use of general anesthesia (which was dangerous for Rowan) for a diagnostic procedure
3. Because of Dr. Raymond Fripp’s label, Dr. Kathleen Kaya was not required to, and did not, provide precautions typical in all general anesthetic procedures
4. Because of #2 and #3, Rowan was killed
5. And finally, because Rowan had a special needs diagnosis, the hospital was able to justify his abysmal care. Because Rowan had special needs, the California Department of Health was able to support the hospital’s justification, and the Medical Board of California was able to ignore it.

The California Department of Public Health has reached a conclusion of their investigation into Rowan’s death. In their verbal report, they state that the hospital’s policies for anesthesia and the physical environment met all current state standards and they find no regulatory deficiencies. Rowan’s case at the California Department of Public Health is now closed.
In interviews with doctors, the CDPH investigated:

FAILURE TO PLACE AN IV LINE PRIOR TO ANESTHESIA FOR ROWAN. The hospital claims that Rowan was so much at risk from cardiac arrest they didn’t put in an IV line as the “agitation” and crying could kill him. (see “Rowan is uncooperative”)

PLACING ROWAN UNDER GENERAL ANESTHESIA FOR A DIAGNOSTIC EXAM. The hospital claims that Rowan was more than healthy enough, in fact was cleared following a superficial cardiac examination, to follow the general anesthesia guidelines for the general population.

So, Rowan’s physicians and the hospital are saying he was healthy enough for general anesthesia (clearly shown by multiple studies to carry high risk of sudden death for children like Rowan), but not healthy enough to put in the IV line (or any other pre-anesthetic monitoring) that could have saved his life.

As a comparison, it would be negligent to perform general anesthetic induction on an adult with even one significant risk factor for congestive heart disease without placing an IV line prior to induction to maintain hemodynamic balance and allow rapid drug intervention in case of emergencies.

Current recommendations for general anesthesia in children with WS like Rowan highlight the critical importance of maintaining adequate hydration and blood-fluid balance during anesthetic induction. This is almost always done using IV fluids via the placement of an IV line. An IV line also allows for rapid life saving drug administration in the case of sudden cardiac arrest. We know of at least one other child with WS who died under anesthesia, and the hospital claimed that dehydration was the cause. As anesthetic induction is now considered high risk for children with WS, the physical presence of life saving equipment (an example is called ECMO, that takes over the function of the heart) in the room where anesthesia is administered is also highly recommended. None of these recommendations were followed for Rowan, were in fact deliberately ignored, yet all of this is well within acceptable policies and regulations.

The glaring contradiction that Rowan was 1. Too unhealthy and easily agitated for pre-anesthetic monitoring or precautions and 2. Healthy enough for no precautions at anesthetic induction was fully accepted by the CDPH investigating physician as being compliant with acceptable procedures and policies. When we asked the CDPH representative to explain this contradiction, he could not. He could only say, “The CDPH is not responsible for overseeing the doctors’ decisions”.

That the CDPH accepts this clearly bizarre and insulting contradiction and has closed their investigation with no findings against the hospital is insulting, and demonstrates just how systemic the institutionalized suppression of medical malpractice has become. The CDPH justification is that the hospital’s policies on anesthesia (again – it is only institutional policy that CDPH investigates) need to be broad as they have to cover a broad range of patient needs. This justification is an exact representation of the systematic failure and “treating to the average” that lead directly to Rowan’s death.

It is completely unacceptable that Rowan was not seen as an individual with specific medical requirements, despite our loud and repeated concerns. If anyone is in doubt that individuals with special needs are the forgotten minority, this should be a wake-up call. The acceptable policies are boilerplate, sub-standard and no regulatory mechanism exists for the protection of children like Rowan, who are rare, differ from the norm and are uniquely at risk within our medical system.

(Please note the CDPH does not investigate medical errors or malpractice as performed by individual doctors etc.. That is investigated by the California Medical Board, who we have petitioned. To this date, nearly one year after Rowan’s death, we have received no response form the California Medical Board).

UPDATE: The above is based on a verbal conversation. When we received a written letter a month later, it stated ““a common practice in pediatrics to not insert an IV line prior to anesthesia induction”

“Researchers interviewed people who had been hospitalized in 16 institutions about their own experience and checked it against medical records. Twenty-three percent said they’d had at least one “adverse event,” although only about half of those were documented in their record.”

Though much of the article was more disturbing than uplifting, I am glad to see the positive action and great efforts that are taking place in Massachusetts. Though too late for our family, we hope to see the same efforts taking place in California someday.

PS – For those that may wonder about this part of the article: “.. acknowledges that nondisclosure hasn’t worked — that involving only health care insiders and state bureaucrats is not getting the job done. “We do need to get beyond the inside game,” she says. “The doors need to be thrown open and other voices need to be heard — particularly the consumer voice.” But that doesn’t mean, she adds, that names and details of particular errors need to be made public.”

Please know that we completely agree, and we do not feel we make this statement in a hypocritical manner. Please know that the original version of this website contained no names, and public disclosure of Rowan’s doctors and hospital was only done after many months of attempts for transparency. This disclosure was only made after we felt that our option to keep their identities private was exhausted. We continue to feel that the only way for the hospital and doctors to address this act of negligence is to expose their names, and we hope that a time will come when we feel safe removing their names from this website.

These are the words that are being used to justify the killing of our amazing son Rowan.
These are the words that the hospital is using to justify not using (not even attempting to use) an IV catheter, or any another precautions or monitoring before the careless use of general anesthesia.
These are the words that the hospital is using to justify the unnecessary use of general anesthesia for a diagnostic procedure.Rowan did nothing to deserve this description, other than that he looked different than you or I. Nothing other than being born with Williams Syndrome.

Rowan was happy, playing, and cooperative before anesthetic induction. He was cooperative and without tears as the anesthesia began to flow into his body.

Rowan regularly visited doctors throughout his life, and cried occasionally, just like every other kid. He cried: 1. Once when he had to fast for 15 hours (12:00 am to 3:30pm) and cried because he was (very) hungry, 2. Once because he had an ophthalmology appointment that lasted for five hours, 3. When he was put on an infant scale (he was happy once he got big enough for a big kid scale), and 4. ONCE (out of five cardiology appts) because he was initially scared of Dr. Fripp. He did not cry for the pediatrician, Rady’s own ophthalmologist, Rady’s own geneticist, or Rady’s own physical therapist, though he did not prefer the dentist. Oh, and he cried at the grocery store when he didn’t get the food he wanted.

Rowan sat still and happily for blood draws without a tear, received ultrasounds without sedation, and was fascinated by whirring machines. Rowan flirted with nurses, and relaxed in my lap many times when his heart was listened to, he had his blood pressure read, or he received an EKG. Rowan consistently received positive notes from his therapists and teachers about his cooperative nature and willingness to participate.

Rowan was a very cooperative child, who was given a label because he had special needs. And that label killed him.

We are beyond infuriated, but we will not meet this injustice with anger. Instead, we will show the world the real Rowan.

Please join us in asking Chief Medical Examiner Wagner to re-open an investigation into Rowan’s death. Your letters can be sent to:

Chief Medical Examiner Wagner

5570 Overland Ave.
Suite 101
San Diego, CA 92123-1206

or call: (858) 694-2895

Police Chief Shelley Zimmerman

Headquarters
1401 Broadway, San Diego, CA 92101
Phone: (619) 531-2000

June 27, 2014

Dear Chief Medical Examiner Wagner,

Our two-year old son Rowan was killed during an outpatient diagnostic procedure whilst under the care of physicians at Rady Children’s Hospital division of pediatric cardiology. Your office’s representative was quick to determine that his death did not warrant further investigation, a decision that I firmly believe was incredibly premature and incorrect.

Our own subsequent research has led us to the objective conclusion that Rowan was killed, not due to a “Pre-existing condition” as stated in his post mortem medical records and on his death certificate, but due to gross negligence on the part of his anesthesiologist (Dr Kathleen Kaya) and primary cardiologist (Dr Raymond Fripp).

The information about the details of Rowan’s negligent care has been actively suppressed by others at Rady’s, including the Chief of Cardiology Dr John Moore and the head of quality assurance Dr Irvin Kaufman. This includes, but is not limited to: misrepresenting the primary reason for performing the procedure that led to Rowan’s death in the post mortem medical records (namely identification of coronary artery stenosis by CT scan) and withholding of documents which reveal this negligence.

Each of Rowan’s physicians repeatedly failed to provide the necessary and easily available information on anesthetic risk for children like Rowan, making it impossible for our family to provide informed consent for any anesthetic procedure. Rowan’s anesthesiologist, Dr Kathleen Kaya also agreed to a written statement that she was “well versed in the anesthetic risk associated with William’s Syndrome” before we allowed her to have Rowan under her care. Consequently, general anesthesia was administered to Rowan under grossly negligent and substandard conditions that were far below the reported standard of care for children with William’s Syndrome. It is this fact that led directly to Rowan’s death, not the presence of a pre-existing condition.

Despite written assurances from Dr Donald Kearns and Dr Irvin Kaufman that an independent external review of Rowan’s death would be performed, no such review has ever been initiated, and we have received no further communication from anyone at Rady Children’s hospital.

I ask that you re-open your investigation into the criminal medical negligence that led to Rowan’s death at the earliest opportunity. It is now a matter of public record that there is a culture of silence and denial of responsibility within the medical community in San Diego. Do not let this continue, and let other families suffer the loss of a child and the pain of being denied the details of a loved one’s death.

I hope to hear from you regarding your department’s investigation into my son’s death immediately upon receipt of this letter.

Rowan was killed at a renowned children’s hospital as a direct result of the careless and unnecessary use of general anesthesia for a “routine” outpatient diagnostic procedure .. against his mother’s wishes.

Want to help make a difference? Visit How To Take Action to speak out against medical negligence and special needs discrimination in healthcare.
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